Torsion of a large subserosal fibroid along with omental torsion adherent to it: a rare cause of acute abdomen.

A woman in her 30s presented to emergency with complaints of acute lower abdominal pain for 3 days, not associated with any menstrual, bowel or urinary symptoms. Examination revealed an abdominopelvic mass corresponding to an 18-week gravid uterus with diffuse tenderness and guarding over her lower abdomen. The patient was a follow-up case of subserosal fibroid uterus, chronic kidney disease stage 4 and rheumatic heart disease on anticoagulants. Fibroid degeneration or torsion was suspected. Ultrasound revealed a large posterior wall subserosal fibroid with free fluid in the pelvis. As findings did not suggest degeneration or pedunculated fibroid, noncontrast CT was done, which showed a similar mass with a pedicle arising from the uterine fundus with free fluid with no other evident cause of acute abdomen. The patient was taken up for emergency laparotomy. Intraoperatively, it was found to be a case of subserosal fibroid with greater omentum adhered to it and twisted around its axis about eight times. This case is being reported to highlight a rare cause of acute abdomen.

Invasive pneumococcal disease serotype 23B1 causing multifocal septic arthritis, myositis and retroperitoneal abscess.

We describe a case of a previously healthy unvaccinated man in his 70s who developed penicillin-susceptible bacteraemic invasive pneumococcal disease due to non-vaccine serotype 23B with the unusual manifestations of multifocal myositis, intramuscular abscesses, polyarticular septic arthritis and synovitis. Blood cultures drawn prior to antibiotic therapy and culture of iliopsoas collection were helpful in making the diagnosis. At follow-up, he had persistent hip pain attributed to avascular necrosis of the head of femur, a possible late complication of his pyomyositis.

Renal abscess complicating acute pyelonephritis in children: Two cases report and literature review.

RATIONALE: To describe the diagnostic and treatment approaches of renal abscesses complicated with acute pyelonephritis in children. PATIENT CONCERNS: Two children presented with fever, vomiting, and abdominal pain with no typical manifestations, like frequent urination, urgency, dysuria, hematuria, foam urine, and lumbago. Renal abscess complicating acute pyelonephritis was diagnosed by B-ultrasound and computed tomography enhancement. Moreover, inflammatory markers were elevated significantly, but routine blood and urine cultures were repeatedly negative. The empirical anti-infection therapy had no obvious effect. A pathogenic diagnosis was confirmed in case two, and macro gene detection in blood and urine guided the follow-up treatment. DIAGNOSES: Both children were diagnosed with acute gastroenteritis on admission, but renal abscess complicating acute pyelonephritis were diagnosed by imaging examination. INTERVENTIONS: Both children were given anti-infection therapy of third-generation cephalosporin, which had no obvious effect. Routine blood and urine cultures were repeatedly negative. Case one was changed to piperacillin sodium tazobactam. We further carried out blood and urinary metagenomic next-generation sequencing detection for case two. Meanwhile, meropenem and linezolid anti-infection treatment was given. The results showed overlapping infection with Escherichia coli and Enterococcus faecalis. According to the genetic test results, amoxicillin clavulanate potassium combined with nitrofurantoin were prescribed after discharge. OUTCOMES: Clinical symptoms of the 2 children disappeared, the infection was controlled, and imaging showed that renal abscess complicated with acute pyelonephritis disappeared. LESSONS: The clinical spectrum of renal abscess complicating acute pyelonephritis is vague, with no specific manifestations, and can be easily misdiagnosed. B-ultrasound and computed tomography enhancement are helpful in making a definite diagnosis. Moreover, the sensitivity of routine culture is low, and metagenomic next-generation sequencing might be helpful to detect pathogenic microorganisms and guided treatment. Early treatment with broad-spectrum antibiotics might have favorable outcomes.

Hydrocele and endometriosis of the canal of Nuck in two adults: a look at the imaging features.

We present a report of two adult females who presented to the surgery clinic at different time frames in our hospital with a swelling in the inguinal region. The swelling was painful for one of our patients. The first patient was evaluated with a contrast-enhanced CT and an MRI, while the second patient underwent a ultrasonography and an MRI. Imaging revealed the structure to be cystic in nature and confirmed the diagnosis as a hydrocele of the canal of Nuck in both patients. Our second patient was also found to have concomitant endometriosis, with internal septations seen in the hydrocele. Aspiration revealed altered blood with haemosiderin deposition, which established a diagnosis of endometriosis of the canal of Nuck. The first patient underwent excision, while the second patient refused a surgical approach and opted for medical management for endometriosis.

Mechanisms of peripheral sensitization in endometriosis patients with peritoneal lesions and acyclical pain.

PURPOSE: Endometriosis (EM) is one of the most frequent differential diagnoses concerning chronic pelvic pain. Women under hormonal therapy (HT) often benefit from it but sometimes suffer a setback and develop acyclical pelvic pain. Due to the assumption that mechanisms of neurogenic inflammation are involved in the generation of chronic pelvic pain, we aimed to investigate the expression of sensory nerve markers in EM-associated nerve fibers of patients with/without HT. METHODS: Laparoscopically excised peritoneal samples from 45 EM and 10 control women were immunohistochemically stained for: PGP9.5, Substance P (SP), NK1R, NGFp75, TRPV-1, and TrkA. Demographics and severity of pain were documented. RESULTS: EM patients showed a higher nerve fiber density (PGP9.5 and SP) and increased expression of NGFp75, TRPV1, TrkA, and NK1R in blood vessels and immune cells compared with controls. Patients with HT have cycle-dependent pelvic pain but suffer from acyclical pelvic pain. Interestingly, reducing NK1R expression in blood vessels under HT was observed. A correlation between dyspareunia severity and nerve fibers density and between NGFRp75 expression in blood vessels and cycle-dependent pelvic pain severity was observed. CONCLUSION: Patients under HT have no ovulation and no (menstrual) bleeding, which correlate with inflammation and cyclical pain. However, acyclical pain seems to be due to peripheral sensitization once it is present under treatment. Neurotransmitters, like SP and their receptors, are involved in mechanisms of neurogenic inflammation, which are relevant for pain initiation. These findings indicate that in both groups (EM with/without HT), neurogenic inflammation is present and responsible for acyclical pain.

Case Report: A Child With Omental Infarction.

BACKGROUND: Omental infarction (OI) is a rare cause of acute abdominal pain, which is benign and self-limited. It is diagnosed by imaging. The etiology of OI is either idiopathic or secondary and due to torsion, trauma, hypercoagulability, vasculitis, or pancreatitis. CASE REPORT: Here, we present a case of OI in a child with acute severe right upper quadrant pain. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Correct diagnosis of OI via imaging can prevent unnecessary surgery.

Omental infarction mimicking acute appendicitis with negative radiological findings.

A male in his 30s presented to the emergency department with a 1-day history of supra-umbilical pain migrating to the right iliac fossa. On examination, his abdomen was soft but tender with localised guarding in the right iliac fossa and a positive Rovsing's sign. The patient was admitted under a presumptive diagnosis of acute appendicitis. A CT scan and ultrasound scan of the abdomen and pelvis showed no acute intra-abdominal pathology. He stayed in hospital for 2 days for observation without improvement of symptoms. A diagnostic laparoscopy was therefore performed that revealed an infarcted omentum adherent to the abdominal wall and ascending colon causing congestion of the appendix. The infarcted omentum was resected, and the appendix was removed. The CT images were reviewed by multiple consultant radiologists, but no positive findings were appreciated. This case report demonstrates the potential difficulty in diagnosing omental infarction clinically and radiologically.

Platelet-rich Plasma Gel versus Hyaluronic Acid on Prevention of Peritoneal Abdominal Adhesion Formation in Rats.

Background: Intra-abdominal adhesion formation is still unavoidable and a cause of significant morbidity in abdominal surgery. Platelet-rich plasma gel and hyaluronic acid have been studied for their protective of therapeutic effects on adhesions. The aim of the present study is to compare Platelet-rich plasma and hyaluronic acid in adhesion prevention. Material and method: Twenty-seven Sprague-Dawley rats were randomly allocated into three equal groups(n=9). Surgical trauma was used to induce adhesion formation. After trauma, 1 ml normal saline was instilled in the peritoneal cavity in control group (n=9), 1 ml liquid Hyaluronic acid (25 mg/ml) was instilled in group A (n= 9) and 1 ml of platelet-rich plasma was instilled in group B (n = 9). Four weeks after the laparotomy, a repetitive laparotomy was performed and adhesions were examined microscopically and macroscopically. Results: Platelet-rich plasma gel and hyaluronic acid both reduce the extent and grade of adhesions macroscopically. Interestingly, PRP turns out to be superior in the reduction of tenacity and adhesion area. Moreover, platelet-rich plasma ameliorates abdominal adhesion formation by reducing neutrophils, fibrosis, and inflammation. Conclusion: The results indicate that platelet-rich plasma gel surpasses hyaluronic acid in abdominal adhesion prevention.

Omental torsion as a rare cause of pain in the right subcostal space - a case report.

Omental torsion is a rare cause of abdominal emergency. Due to its clinical presentation and according to its localisation it is seldom diagnosed preoperatively as it imitates other more common diagnoses leading to surgical revision quite precisely. In this case report the authors present omental torsion with partial omental necrotisation in the right upper quadrant, imitating acute cholecystitis. The condition was managed by laparoscopic resection with a good clinical course postoperatively.

Acute abdomen caused by torsion of the omentum: A pediatric case report.

RATIONALE: Torsion of the omentum and infarction are rare and unusual disorders that often present as acute abdominal pain in the population. The diagnosis of omental torsion is based on clinical and imaging examinations. PATIENT CONCERNS: A 7-year-old girl presented with acute right lower quadrant abdominal pain, with symptoms resembling acute appendicitis. DIAGNOSIS: The patient was diagnosed with omental torsion based on imaging and laparoscopy. INTERVENTIONS: Laparoscopic exploration was performed. OUTCOMES: The patient was discharged seven days after satisfactory postoperative recovery. LESSONS: Omental torsion should be included in the differential diagnosis of acute abdominal pain, particularly in patients with free hemorrhagic fluid in the abdominal cavity and pelvis.

Case Report: Development of Miliary Pulmonary Tuberculosis in a Patient with Peritoneal Tuberculosis after COVID-19 Upper Respiratory Tract Infection.

We report a 29-year-old patient who presented with coronavirus disease 2019 (COVID-19) upper respiratory tract infection in addition to clinical, laboratory, and radiological findings highly suggestive of peritoneal tuberculosis (TB) without pulmonary involvement. Two weeks after the resolution of COVID-19 infection, he presented with shortness of breath and oxygen desaturation requiring intubation and admission to the intensive care unit. The workup confirmed miliary pulmonary TB. The patient subsequently improved on antitubercular treatment. We discuss the possible contribution of COVID-19 infection to the rapid progression of TB infection to involve the lung in a miliary pattern, and how the coexistence of the two diseases might have led to a worse outcome.

Surgical treatment of deep endometriosis with adenomyosis externa: a challenging case in an infertile woman.

OBJECTIVE: To describe the management and the fertility-enhancing potential of surgery in an infertile patient with deep-infiltrating endometriosis and adenomyosis externa. DESIGN: Video case report. SETTING: Minimally invasive and robotic gynecologic surgery unit of a university hospital. PATIENT(S): A 31-year-old nulliparous patient with dysmenorrhea, dysuria, dyspareunia, and primary infertility. INTERVENTION(S): Bimanual examination, transvaginal ultrasound, and magnetic resonance imaging (MRI) were performed as a comprehensive preoperative workup. The findings were consistent with bladder endometriosis and a 4-cm right pararectal cystic mass suggestive of adenomyosis externa. Laparoscopic excision of all visible endometriosis was performed. A pararectal lesion was found, completely developing in the retroperitoneal spaces, from the right medial pararectal space to the rectovaginal space, reaching the pelvic floor fascia without infiltration of the levator ani muscle. According to Koninckx classification, this kind of lesion corresponds to type III endometriosis or adenomyosis externa. Nerve-sparing eradication of the nodule was performed. The decision to use these techniques was taken with the intention to treat the patient, and not with the aim of testing the procedures performed. Therefore, as a common clinical practice in our institution and for the above reasons, there was no need for consultation of the institutional review board for approval. MAIN OUTCOME MEASURE(S): Improvement of symptoms and spontaneous conception after surgical removal of all endometriotic implants. RESULT(S): There were no intraoperative or postoperative complications, and the patient was discharged after 3 days. She discontinued postoperative hormone therapy with gonadotropin-releasing hormone analogue after 3 months because she desired fertility. She conceived spontaneously after 2 months of attempting. She delivered vaginally and had no complications during pregnancy and labor. Neither recurrence of pain symptoms nor voiding or rectal dysfunctions were reported by the patient. CONCLUSION(S): In the management of a case of deep endometriosis, the preoperative assessment should be carefully carried out to give the surgeon the most accurate information about the extent of the disease and the patient's main objectives. Imaging techniques such as ultrasound and MRI play a fundamental role along with the clinical evaluation in also detecting lesions that are not visible at first laparoscopic inspection. In this case of a young woman without any detectable fertility issues except for endometriosis, the laparoscopic excision of endometriosis was feasible, safe, and effective in improving the patient's fertility and pain symptoms. The fertility-enhancing potential of complete eradication of pelvic endometriosis, including removal of deep posterior localizations such those presented in this case, has been hypothesized by various investigators. It has been suggested that skilled surgical management for symptomatic deep endometriosis may be followed by a high pregnancy rate, with most pregnancies resulting from postoperative natural conception even in patients with primary infertility.